Healthcare Provider Details

I. General information

NPI: 1225054000
Provider Name (Legal Business Name): LONGS DRUG STORES CALIFORNIA INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/14/2006
Last Update Date: 03/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

760 WASHBURN AVE #2
CORONA CA
92882-3303
US

IV. Provider business mailing address

FILE 73241 P.O. BOX 60000
SAN FRANCISCO CA
94160-0001
US

V. Phone/Fax

Practice location:
  • Phone: 951-738-1669
  • Fax: 951-738-1779
Mailing address:
  • Phone: 925-210-6659
  • Fax: 925-210-6606

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPHY47568
License Number StateCA

VIII. Authorized Official

Name: AMY M HALLIDAY
Title or Position: MANAGED CARE ADMINISTRATOR
Credential:
Phone: 925-210-6659